Towards a Quantum Theory of Health

We're pretty proud of modern medicine.  We've accumulated a very intricate understanding of how our body works, what can go wrong with it, and what are options are for tinkering with it to improve its health.  We've got all sorts of tests, treatments, and pills for it, with more on the way all the time.

However, there has been increasing awareness of the impact our microbiota has on our health, and I think modern medicine is reaching the point classical physics did when quantum physics came along. 

Classical physics pictured the atom as kind of a miniature solar system, with well-defined particles revolving in definite orbits around the solid nucleus.  In quantum physics, though, particles don't have specific positions or exact orbits, combine/recombine, get entangled, and pop in and out of existence.  At the quantum level everything is kind of fuzzy, but quantum theory itself is astoundingly predictive.  We're fooled into thinking our macro view of the universe is true, but our perceptions are wrong. 

So it may be with modern medicine.  Our microbiota (including both the microbiome and mycobiome) both provide the fuzziness and dictate a significant portion of our health. 

Two articles in Science illustrate how we're still just scratching our understanding of their impact.  The first, from Rodrigo Pérez Ortega, reports on two new studies.

The first study found that the genetic structure of gut microbiome was more predictive of health than one's own genes.  It was especially better for "complex" diseases that are attributed to both environmental and genetic factors.  Gut microbes are impacted sooner by environmental factors and thus serve as better predictors for such diseases.

The second study found that a person's microbiome could be used to predict their death 15 years later.  Presence of a certain family of bacteria led to a 15% higher mortality rate in the next 15 years.  Whether the bacteria are the cause of the mortality or a side effect of other factors is not clear.

Credit: Finlay, et. al, Science Magazine

The second article was a study from B.B. Finlay, et. alia, that speculated that so-called non-communicable diseases (NCD) might actually be communicable, via the microbiome.  I.e., "we propose that some NCDs could have a microbial component and, if so, might be communicable via the microbiota."

The authors looked at obesity, Type 2 diabetes, cardiovascular disease, and inflammatory bowel disease as possible examples.  "These observations suggest that the microbiota could be a causal and transmissible element in certain diseases that have been traditionally classified as NCDs," the authors conclude, further noting: "Additionally, only gut bacteria have been considered in this discussion, yet viruses and fungi may also contribute to NCDs, as well as microbiota at other body sites such as the skin and oral cavity."

Their paper concludes:

These findings could serve as a solid framework for microbiome profiling in clinical risk prediction, paving the way towards clinical applications of human microbiome sequencing aimed at prediction, prevention, and treatment of disease.

Dr. Finlay says: "If our hypothesis is proven correct, it will rewrite the entire book on public health."

Microbiome researcher Samuel Minot, PhD, who was not involved in the studies, is told Mr. Ortega, "I am hopeful and enthusiastic that the community will reach a point where we’re able to develop microbiome-based therapeutics and diagnostics.  I think that this is within the realm of possibility." 

Professor Harry Sokol of the Paris Center for Microbiome Medicine agreed, telling Gut Microbiota for Health: "I am convinced that some microbiome-based tests will become biomarkers in many clinical situations in the future."  

There is much work going on in the field.  For example, The Cleveland Clinic has the Center for Microbiome and Human Health, the Mayo Clinic has the Microbiome Program, Stanford has the Stanford Microbiome Therapies Initiative, UCSF has the Benoff Center for Microbiome Medicine, the University of Pittsburgh has the Center for Medicine and the Microbiome, and the University of Wisconsin has the Center for Microbiome Sciences & Therapeutics.

Still, it is too early to get overly excited.   Everyone agrees more research is necessary.  Timothy Caulfield, the Research Director of the Health Law Institute at the University of Alberta, warns: "Gut hype is everywhere."  He acknowledges that this is an exciting field with great promise, but cautions "it is still early days for microbiome research." 

Think of modern medicine, with its germ theory of disease and its understanding of our body's biomechanics, as classical physics.  See a germ, kill a germ.  Monitor our bodily functions, test our blood, even sequence our genes; all the answers lie within us.  Newton would approve.

Our recent discoveries about our microbiota are upending our notions about what disease is, what causes it, and how we should best deal with it.  Our supposed precision in medicine is illusionary. Heisenberg would understand. 

Credit: KATERYNA KON/SCIENCE PHOTO LIBRARY, VIA GETTY IMAGES

Modern medicine loves its antibiotics, despite the devastating impact they wreak on our microbiome.  It is fascinated with our genome, despite the fact that our microbiota's genes greatly outweigh our own, and have more diversity.  Our microbiota change in ways that we don't understand and, as yet, can't even really track, much less predict the effect of.  

We need the equivalent of a quantum theory of health. 

I don't mean literally applying quantum physics to healthcare, although, of course, we are a collection of quantum bits.  I mean recognizing that our human-centric picture of health is much too narrow, and fails to predict what actually drives our health.  I mean admitting that "our" health is really a consequence of "their" health, and that only figuring out how to incorporate both will yield us a true picture of health. 

Modern medicine is in the stage physics was in the early part of the 20th century, when the concept of quanta was known but the consequences of it were yet to be discovered.  Physics struggled for many years to accept quantum theory, and medicine will have a similar struggle to accept whatever the theory that fully incorporates microbiota will be. 

Modern medicine has had its Newtons, maybe even its Einsteins, but now it needs a new generation of scientists to develop more accurate theories of our health, no matter how counter-intuitive they might be. 

Welcome to a quantum theory of health.

Your Wealth Is Your Health

We've been spending a lot of time these past few years debating healthcare reform.  First the Affordable Care Act was debated, passed, implemented, and almost continuously litigated since.  Lately the concept of Medicare For All, or variations on it, has been the hot policy debate.  Other smaller but still important issues like high prescription drug prices or surprise billing have also received significant attention.

As worthy as these all are, a new study suggests that focusing on them may be missing the point.  If we're not addressing wealth disparities, we're unlikely to address health disparities. 

It has been well documented that there are considerable health disparities in the U.S., attributable to socioeconomic status, race/ethnicity, gender, even geography, among other factors.  Few would deny that they exist.  Many policy experts and politicians seem to believe that if we could simply increase health insurance coverage, we could go a long way to addressing these disparities, since coverage should reduce financial burdens that may be serving as barriers to care that may be contributing to them.

Universal coverage may well be a good goal for many reasons, but we should temper our expectations about what it might achieve in terms of leveling the health playing field.

The new study, by Paola Zaninotto, PhD, et. alia, in The Journals of Gerontology "examined socioeconomic inequalities in disability-free life expectancy."  It compared cohorts from England and the U.S., looking not just at life expectancy but also how healthy those lives were, as measured by presence of disability -- the "disability-free" life expectancy.  Long study short:

people in the poorest group could expect to live seven to nine fewer years without disability than those in the richest group at the age of 50.  

The study looked at men versus women, at different ages, by disability level and wealth status.  Most importantly, it compared results for those in England versus the U.S.  The authors found that: "we showed that within each country, there was a consistent advantage for people in high socioeconomic groups, particularly for wealth and education, so that they could expect to live a higher number of years without disability."  

Source: Zaninotto, et. alia, The Journals of Gerontology

Dr. Zaninotto told Yahoo:

We were not surprised.  In fact, the reason for looking at wealth and not income is that we know how important a socioeconomic indicator it is. This measure of wealth is based on housing, savings, investments — something that takes a long time to accumulate. It’s a measure of past and present circumstances.

Still, when it came to the similarities between the two countries, Dr. Zaninotto admitted: "It was surprising to find that the inequalities are exactly the same."  

It was surprising because, unlike the U.S., England does have universal coverage.  The National Health Service provides access to care to everyone, without financial burdens.  There may (or may not) be access issues with the NHS, but they are not, for the most part, financially-driven.  And yet the differences of the impact of wealth on health between the two countries are similar.

One could speculate that the wealthy in England are somehow buying their way into better care -- perhaps jetting off to Switzerland or even the U.S. -- but that is unlikely to account for those seven to nine extra years of disability-free life they are getting.  

It's about the money.  

There has been much furor about the obesity crisis in the U.S., with the childhood obesity crisis presenting a ticking time bomb for future health care problems.  Same for diabetes.  But what we're not paying enough attention to is that a wealth crisis is looming for younger people as well, which the new findings suggest will result in major health implications.  

Economist Gary Kimbrough has been studying the upcoming wealth gap, with some alarming results:

Millennials are way poorer than previous generations at their age, burdened by student debt and stagnant wages.  Christopher Ingraham, writing in the Washington Post, warns:

It’s a hole they’ll never truly be able to dig out of, given the way that money draws other money to itself via the gravitational pull of compound interest: The less money you start out with, the less you’ll make during the rest of your life.

 Some argue that it will all be OK, they'll eventually inherit significant wealth from their parents --"the Great Wealth Transfer" -- but that assumes that those parents won't end up spending that inheritance on their own health care and other financial needs. 

Equally as worrisome, it ignores the adverse health impacts that the reduced wealth is already having on their health.  Lack of wealth is not the only hole that you may never be able to dig out of; poor health is at least as hard. 

Dr. Zaninotto thinks the results should be a call to action, telling Yahoo: 

We really think this inequality should be addressed much earlier in life.  When people are older, you can’t give them an education — it really should start much earlier in life. It’s looking at improving opportunities across community and education much earlier and trying to help younger people to buy a house. It seems it is quite important.  

The U.S. could, and should, move to universal coverage.  It is the right thing to do.  We could, and should, find ways to lower costs, both for coverage and for care.  It is the right thing to do.  But we shouldn't expect that those actions would level the unequal playing field that wealth creates.  

We need to address affordable housing.  We need to reduce student debt burdens.  We need to ensure people are paid living wages.  We need to provide parents with affordable child care options, such as  day care, preschool, after-school programs.  

Arguably, these are more important than universal coverage, or at least their long-term impacts on health will be greater.  

We can't, and shouldn't, try to equalize wealth.  That's not what America is about, and not what most Americans want.  But there are some aspects of life where wealth should make less of a difference.  It shouldn't determine opportunity, and, as these findings suggest it does, it shouldn't dictate health.    

Healthcare Might Look Good in Plaid

I don't really follow FinTech -- I can't even keep up with HealthTech! -- but it caught my eye when Visa announced that it was acquiring FinTech company Plaid for $5.3b; a 2018 funding round valued the company at $2.65b.  A 100% increase in valuation within a year suggests that something important is going on, or at least that people think something is.  

I suspect there may be some lessons for healthcare in there somewhere.  

For those of you who are equally as unfamiliar with FinTech's terrain, Plaid has been described as the "plumbing" that supports many other FinTech companies.  Launched in 2013, one in four people with a U.S. bank account are now believed to use Plaid to connect with 2,600 FinTech developers connected to more than 11,000 financial institutions.  Its customers include Acorns, Betterment, Chime, Coinbase, Gemini, Robinhood, Transferwise, and Venmo.  Plaid claims it connects with 200 million consumer accounts.  

What terrifies Visa and rival Mastercard is that the future may be less card (credit/debit)-centric.  In 2015, only 18% of internet-connected consumers worldwide had used a FinTech app to move money; in 2018 75% had.  Plaid is one of the services that allow for such movement.  

Rival Mastercard hasn't been sitting idly; it had previously acquired FinTech companies VocaLink for $1b in 2016 and Nets for $3.2b in 2019, and had been an investor in Plaid.  It has been trying to describe itself as a "multi-rails payment company."

In a call with analysts, Visa CEO Al Kelly admitted:  

We are increasingly trying to move from being strictly focused on payments, to being focused on the movement of funds for any purpose around the world.  As big as Visa is in terms of the bank accounts that we can reach, we’re not as big as we need to be if we want to be a formidable player in money movement around the world.

Techcrunch says that what Plaid's APIs do "is akin to what Stripe does for payments, but instead of facilitating payments, it helps developers share banking and other financial information more easily."  It adds that, with the acquisition, Visa "now has a view into scads of high-growth, private companies that are reinventing the world in which Visa operates. Buying Plaid is insurance against disruption for Visa, and also a way to know who to buy."

CEO Mr. Kelly praised the acquisition, noting: "Plaid opens up new market opportunities by significantly expanding Visa’s network capabilities.”  Mr. Kelly predicted that the acquisition would "expand a new financial data network” and  add “new growth in core, as we work more closely with fintechs."  

Similarly, Visa President Ryan McInerney told Fortune:  "Fintechs are clearly reshaping financial services, and Plaid is unquestionably the leader in this space...It’s something that positions Visa for the next decade and beyond."  

Meanwhile, healthcare struggles to share our data even between healthcare institutions using the same platforms, can't seem to uniquely identify us, and is always trying to figure out who to chase for how much payment.  It's slow, inefficient, inaccurate, and very expensive.  

There are companies like Noyo that are trying to change that.  It describes itself as "modern architecture for health insurance," and "the first API integration platform for health insurance."  Crunchbase even went so far as to say Noyo is "a sort of Plaid for health insurance data," which Noyo liked so much that it quotes that description on its home page.  

Founded in 2017 by veterans of troubled benefit software company Zenefits, Noyo has raised $4 million, and is still in the early stages of partnerships with carriers.  Similar to Plaid's strategy, Crunchbase said "Noyo wants its service to become a platform upon which other companies can build, but it doesn’t want to write all the apps."  

Healthcare doesn't talk much about platforms, or at least it didn't until the Mayo Clinic made a splash this past December by hiring the well-known health tech guru John Halamka, MD, as president of the Mayo Clinic Platform.  Mayo describes its platform as "a strategic initiative to improve health care through insights and knowledge derived from data. The technology platform will elevate Mayo Clinic to a global leadership position within digital health care."

Mayo just announced its first platform initiative, the Clinical Analytics Data Platform, "a strategic initiative to improve health care through insights and knowledge derived from data."  As part of the announcement, Dr.Halamka said: 

Platform business models have been a force of disruption in many sectors, and the rapid digitalization of health care is affording us an unprecedented opportunity to solve complex medical problems and improve lives of people on a global scale

Mayo is certainly thinking globally, and it recognizes the opportunities that digital health affords, but I'm not sure that either it or the rest of healthcare see the threats, and opportunities, that platform models present.  I'm not even sure that many in healthcare even understand what "platforms" in healthcare might look like, Noyo notwithstanding.  

There certainly don't seem to be many established healthcare companies that are as determined to be part of disruption in the same way that Visa and Mastercard are.  

Credit/debit cards are well-entrenched in most consumers' lives, especially in developed countries.  Mastercard and Visa are huge, profitable, and seemingly indispensable.  Despite that, FinTech solutions have sprung up to reach more consumers and reduce dependencies on networks like Visa and Mastercard.  They're not waiting to be toppled; they're buying "insurance against disruption."

Healthcare has a data problem.  It is too fragmented, too siloed, too complicated, and too difficult to use and to move.  Its volume is growing exponentially, with more types coming from more sources.  At the same time, more of the payment burden is falling directly on consumers, and they're not happy about it.  

In other words, it is ripe for disruption.  

Disruption in healthcare won't be easy, and it won't come quickly.  Then again, credit/debit cards aren't going away anytime soon either, but Visa and Mastercard are preparing for a future in which they might, or at least in which their role is greatly diminished.  

Healthcare organizations better start buying insurance for disruption that doesn't look much like the current system.  The platforms are coming.

Healthcare Needs Some IHOPs

The New York Times had an article that surprised me: Current Job: Award Winning Chef.  Education: IHOP.   The article, by food writer Priya Krishna, profiled how many high-end chefs credit their training in -- gasp! -- chain restaurants, such as IHOP, as being invaluable for their success.

Credit: Shutterstock/Jonathan Weiss

I immediately thought of Atul Gawande's 2012 article in The New Yorker: What Big Medicine Can Learn From the Cheesecake Factory.

Ms. Krishna mentions several well-known chefs "who prize the lessons they learned — many as teenagers — in the scaled-up, streamlined world of chain restaurants."  In addition to IHOP, chefs mentioned experiences at chains such as Applebee's, California Pizza Kitchen, Chipotle, Hillstone, Houston's, Howard Johnson's, Olive Garden, Panda Express, Pappas, Red Lobster, Waffle House, and Wendy's.  

Some of the lessons learned are instructive.  "It was pretty much that the customer is always right," one chef mentioned.  Another said she learned "how to be quick, have a good memory, and know the timing of everything."  A third spoke to the focus that was drilled into all employees: "Hot food hot. Cold food cold. Money to the bank. Clean restrooms,” 

Oh, gosh, where are the healthcare equivalents of those?

I particularly was struck by three other quotes that could, and should, apply to health

• "There is this understanding that every person is important to making the restaurant run smoothly.  Nobody thought the dishwasher was a lower status than them."
• “You spend a week on the grill, a week waitressing, a week in financials.  You know every aspect of that restaurant.”
• Chain restaurants have a playbook for every position.  There is no guesswork.”

In healthcare., physicians usually get their training in academic medical centers, which is sort of like training chefs in culinary schools or 5 star restaurants.  They learn a lot, see some exotic things, but that experience is similar to what one chef told Ms. Krishna: "a lot of the curriculum in culinary school is not reflective of what is going on in the everyday world."

Physicians are not trained on how the entire system works -- no equivalent of working as a server or in the kitchen first -- and without learning how much things cost.  They tend to develop idiosyncratic approaches that may or may not be based on the latest research/best practices; even if they are, there's no mechanism to ensure that those approaches stay current.  All this while too often tending to see themselves as more important than other healthcare workers.

No wonder Dr. Gawande was impressed by The Cheesecake Factory almost a decade ago.

He marveled at the size of their menu, the quality of the food, and the affordable prices -- all delivered uniformly to tens of millions of customers in two hundred restaurants worldwide.  As he noted:

In medicine, too, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake Factory, we haven’t figured out how. Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital.

Some of the things that impressed Dr. Gawande about the kitchens in The Cheesecake Factory:

• "the instructions [recipes] were precise about the ingredients and the objectives...but not about how to get there."
• "a kitchen manager is stationed at the counter where the food comes off the line, and he rates the food on a scale of one to ten."
• The chain-restaurant industry has produced a field of computer analytics known as “guest forecasting.

Dr. Gawande admitted: "As a doctor, I found such control alien—possibly from a hostile planet."  

He went on to discuss the experience his mother had with a knee replacement; he deliberately steered her to a orthopedic surgeon who had led the charge to standardize such operations at Brigham & Women's Hospital: "they studied what the best people were doing, figured out how to standardize it, and then tried to get everyone to follow suit."  Just like at The Cheesecake Factory, it resulted in lower prices and better outcomes.

Credit: The Cheesecake Factory

One of the other Cheesecake Factory practices that Dr. Gawande was impressed was how they adapt to the new; in their case, new recipes.  First they train representatives from the restaurants on the new recipes, then "...also trained the attendees how to teach what they were learning. In medicine, we hardly ever think about how to implement what we’ve learned. We learn what we want to, when we want to."

Most physicians I know recoil at "cookbook medicine."  Most physicians believe their patients are unique.  But, as Dr. Gawande pointed out: "we’re moving from a Jeffersonian ideal of small guilds and independent craftsmen to a Hamiltonian recognition of the advantages that size and centralized control can bring."

Many of the chefs Ms. Krishna talked to reported there is still a stigma in high-end restaurants of having trained in chain restaurants, and that that culinary schools were still sending most of their graduates to independent restaurants, not chains (even though one such graduate complained: "when you graduate and work for that Michelin-star chef, you aren’t going to make enough to be able to pay your loans."  Physicians can empathize).

But "the more casual, business-minded approach of chains is the future of dining," just as the future of healthcare is more patient-centered and business-minded.   Healthcare may be consolidating, but it is far from replicating the business practices that have made chain restaurant successful.  

We are, in essence, training physicians in expensive culinary schools, to work in high-end restaurants.  That may be good for some of them, and for some of us, but it is not good for all of them or for most of us.  The future is going to require that more of them get healthcare's version of a chain restaurant experience.

Healthcare needs its version of "Hot food hot. Cold food cold. Money to the bank. Clean restrooms.”  and training that instills it in everyone working in healthcare.

Hypersonic Missiles Aimed at Healthcare

The end of one decade and the beginning of another seems to be a time when various pundits like to look back and/or forward.  In particular, I've seen a lot of such articles about tech, both noting important technologies of the 2010's and speculating on the tech coming in the 2020's. 

Oddly enough, the article about new tech that struck me the most was one that seemingly has nothing to do with healthcare, but which I think has important lessons for it.  It is the introduction of hypersonic missiles. 

Avangard missile.  Credit: Russian Defense Ministry

If you don't follow weapons development closely (and I don't usually), hypersonic missiles are ones that can fly at several multiples of the speed of sound, such as Mach 5 and above.  They fly so fast that there is virtually no defense against them.  Existing anti-missile defenses are problematic enough against conventional missiles, but a hypersonic missile is at its target before a defense system can react, due to its speed, low altitude, and maneuverability. 

Russia just claimed that its hypersonic missile, the Avangard, has been deployed.  Some reports claim Avangard can fly as fast as Mach 27.  Russia has been working on the technology for as many as thirty years, tested it in 2016, and in 2018 Vladimir Putin made it public, describing it as: "It heads to target like a meteorite, like a fireball."

The U.S. is also working on hypersonic missiles, but has not made it as high a priority.  Our version is not expected to be available "for a couple of years," according to Defense Secretary Mark Esper.  China, India, and France are also supposedly working on their versions. 

Many experts downplay Avangard's importance.  While it cannot be stopped, it also would not knock out the U.S.'s offensive missile systems, so an attack would still lead to massive retaliation.  Some are also skeptical that the Russian technology will work as promised.

What Putin may like best is that it allows him to boast: "Not a single country possesses hypersonic weapons, let alone continental-range hypersonic weapons...The West and other nations were 'playing catch-up with us.'"

We're spending billions of dollars on aircraft carriers that don't work and fighter plane that don't fly, which seems a little like the old adage that generals are always fighting the last war.  The new wars may be fought in cyberspace, and/or with inexpensive drones and IEDs, not to mention with hypersonic missiles. 

We knew that the technology for hypersonic missiles was possible.  We knew our adversaries were putting an emphasis on developing it.  We knew we'd need some of our own at some point.  And we had a pretty good idea when one of those adversaries would deploy its first instance of the technology.  But we had other, more expensive, more traditional priorities. 

This is what makes me think of healthcare. 

Healthcare is still pouring lots of money into its versions of aircraft carriers (think hospitals), fighter planes (think physicians), and bombers (think prescription drugs).  We're still spend most of our public policy discussions on the need for increasing coverage because our healthcare system is so expensive, rather than admitting that coverage is so important mainly because our healthcare system is so expensive.  Need for coverage is not the problem, it is the result of the problem.

We seem to assume, or at least expect, that our future healthcare system will look very much like our current healthcare system, just more expensive.  What we are not preparing for are healthcare's versions of hypersonic missiles -- technologies that can strike so quickly that our healthcare system can't respond.

As Steven Simon wrote about hypersonic missiles: "If past is prologue, deployment of the systems is going to take place well before their ramifications are fully understood."  We want to try to debate, discuss, and think through all the ramifications before making changes in healthcare, but we may not have that luxury.

For example, many think that CRISPR is going to be a game changer.  We're investigating, using all due caution.  Meanwhile, of course, China is plowing ahead, perhaps with fewer ethical qualms.  They may have sentenced the scientist behind the world's first CRISPR babies to jail, but, meanwhile three such babies have been born. 

The U.S. may have shaky data privacy standards, but what China is doing with aggregating huge data sets is way beyond even our privacy laws, and is helping to fuel their A.I. development.   Healthcare is a key sector. 

There are technologies out there that we know are coming, which people in the U.S. are working on, but for which the regulatory, political, and payment systems we have in place are not at all ready: AI, CRISPR, 3D printing, cybercurrency, among others.  When we all have 24/7 monitoring, and we will, who will have access to that information, who will be obligated to act on it, and will be object?

The example I keep wondering about is: when -- not if -- AI doctors arrive, who will license them, how, for where? 

Healthcare is not prepared for the future, and that future will be sooner than it thinks.

The future is going to be a lot like hypersonic missiles.  It will come fast.  It won't look like what we're used to.  It will arrive before we're really ready for it or can react to it.  And it won't come as a complete surprise. 

Credit: World Economic Forum

The U.S. should be scouring the world for technologies and approaches that deliver the best care in the most cost-effective manner.  There are already many examples, but we think that they are just "developing nations" solutions -- ignoring the fact that some portions of our population suffer developing nations' health outcomes.  We should be trying to crash our existing cost structures, not enable them. 

So, let's be thinking of not how 2030 will be like 2020, but of how it will be different.  Let's spend less time on further developing 2010's technologies and more time delivering 2020's technologies.  Let's make that future what we want, not what we're resigned to. 

If Kara Swisher can imagine our lives without our mobile devices by 2030, what we can imagine for healthcare?